Introduction to Auditing
2017 Safety Groups Advantage Program
Workplace Safety and Insurance Board | Commission de la sécurité professionnelle et de l’assurance contre les accidents du travail
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WELCOME
 Emergency
 Phones
 Break(s)
 Questions
Workplace Safety and Insurance Board | Commission de la sécurité professionnelle et de l’assurance contre les accidents du travail
OVERVIEW
 Objective
 Principles of Auditing
 Audit Process
 Audit Review
Workplace Safety and Insurance Board | Commission de la sécurité professionnelle et de l’assurance contre les accidents du travail
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OBJECTIVE
To provide an introduction to the basic
process of conducting an audit of your
Health and Safety Management System.
Workplace Safety and Insurance Board | Commission de la sécurité professionnelle et de l’assurance contre les accidents du travail
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HSMS
Health & Safety Management System
The documented process that fully
incorporates effective risk management
principles into a health and safety
program.
Workplace Safety and Insurance Board | Commission de la sécurité professionnelle et de l’assurance contre les accidents du travail
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AUDITING
The systematic, independent
and documented process for
obtaining audit evidence and
evaluating it objectively to
determine the extent to which
audit criteria are fulfilled.
Workplace Safety and Insurance Board | Commission de la sécurité professionnelle et de l’assurance contre les accidents du travail
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BASICS YOU MAY ALREADY KNOW
 What do you know about auditing?
Workplace Safety and Insurance Board | Commission de la sécurité professionnelle et de l’assurance contre les accidents du travail
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APPROVED SAFETY GROUP AUDITS
 WorkWell
 WSIB HSMS Review Form
 Certificate of Recognition (COR)
 CSA Z1000
 OHSAS 18001
 ZeroQuest Audit
 PSHSA Q5 Audit
 PSHSA HSMS Audit
 Safe Workplace Ontario Safety Audit
Workplace Safety and Insurance Board | Commission de la sécurité professionnelle et de l’assurance contre les accidents du travail
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WHY AUDIT?
Provide senior management with
objective information on which they
can react to improve their health and
safety activities
Workplace Safety and Insurance Board | Commission de la sécurité professionnelle et de l’assurance contre les accidents du travail
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AUDIT OBJECTIVE
 What you want to achieve with the audit
activity such as:
 Does your HSMS:
 conform to a management system criteria? and;
 identify opportunities for improvement to the
management system
Workplace Safety and Insurance Board | Commission de la sécurité professionnelle et de l’assurance contre les accidents du travail
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PRINCIPLES OF AUDITING
 Audit Scope
 Extent and boundaries of the audit
Note: The audit scope generally includes a
description of the physical locations,
organizational units, activities and processes,
as well as the time period covered.
Workplace Safety and Insurance Board | Commission de la sécurité professionnelle et de l’assurance contre les accidents du travail
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PRINCIPLES OF AUDITING
 Audit Criteria:
 used as a reference against which audit
evidence is measured.
 Advantage program allows different criteria
including:
 HSMS Review Form, WorkWell, COR, etc., AND
 the firm’s health and safety program, policies,
procedures and related documents
Workplace Safety and Insurance Board | Commission de la sécurité professionnelle et de l’assurance contre les accidents du travail
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PRINCIPLES OF AUDITING
 Audit Evidence:
 Documents, records, statements of fact
(Interviews) and observations relevant to the
audit criteria and verifiable.
 Sufficient corroborating evidence, minimum two
different sources of evidence and must include
interviews and observations
 Audit Findings / Conclusions
 Results of the evaluation of the collected audit
evidence against audit criteria.
Note: The audit findings can indicate either
conformity or nonconformity with audit criteria.
Auditing relies on these principles
to make it effective and reliable.
Workplace Safety and Insurance Board | Commission de la sécurité professionnelle et de l’assurance contre les accidents du travail
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AUDIT FINDINGS
 Conformity
 The fulfillment of the audit criteria, which
includes:
 Audit standard
 Policies, procedures and company practices
 Non-conformity
 Non-fulfillment of or deviation from
requirements
 Can be major or minor
Workplace Safety and Insurance Board | Commission de la sécurité professionnelle et de l’assurance contre les accidents du travail
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KEY CONCEPTS – PART 1
 What is auditing?
 systematic, independent and documented
process for obtaining audit evidence and
evaluating it objectively to determine the
extent to which audit criteria are fulfilled
 Why audit?
 Provide senior management with objective
information on which they can react to
improve their health and safety activities
Workplace Safety and Insurance Board | Commission de la sécurité professionnelle et de l’assurance contre les accidents du travail
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KEY CONCEPTS – PART 2
 Auditing Principles
 Scope: extent / boundaries of audit
 Criteria: established requirements against
which audit evidence is evaluated
 Evidence: records, statements of fact
 Findings: evidence compared to criteria
Workplace Safety and Insurance Board | Commission de la sécurité professionnelle et de l’assurance contre les accidents du travail
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AUDIT PROCESS
INITIATING
Document
Review
CONTINUAL
IMPROVEMENT
PLAN
CONDUCTING
THE AUDIT
Evidence
Findings
MANAGEMENT
REVIEW
AUDIT
REPORT
Workplace Safety and Insurance Board | Commission de la sécurité professionnelle et de l’assurance contre les accidents du travail
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INITIATING THE AUDIT
INITIATING
 Management assigns qualified auditor(s)
 Develop an Audit Plan that includes:
 Objectives
 Scope
 Criteria
 Schedule activities with timelines
 Communicate audit activity to appropriate
workplace parties
Workplace Safety and Insurance Board | Commission de la sécurité professionnelle et de l’assurance contre les accidents du travail
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THE AUDIT PLAN
INITIATING
Things to consider:
 Time to review
documentation
 Time to conduct interviews
and observation tours
 Developing a meeting
schedule
 Audit team with roles &
responsibilities
 What PPE is required?
 Floor plan
 Meeting Space
 Access to documents and
records
 Developing audit forms:
•
•
•
Interviews
Observations
Surveys
 List of questions to ask
Workplace Safety and Insurance Board | Commission de la sécurité professionnelle et de l’assurance contre les accidents du travail
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1. WRITTEN HSMS AUDIT STANDARD (pg 3)
Written Company Standard outlining
detailed policy and procedures for your
HSMS Audit Program (internal health &
safety audit) including, at a minimum:
a.
b.
c.
d.
e.
Current date (2017)
Specific reference to your firm
Roles and responsibilities for….
Auditor(s) qualifications
Development of Audit Plan, including audit
criteria, scope, schedule, and timelines
f. Development of a documented CIP ….
Resources /
Tools:
Sample of a HSMS
Audit Program
Standard
2016 SGAP
Timeline
Guide
Workplace Safety and Insurance Board | Commission de la sécurité professionnelle et de l’assurance contre les accidents du travail
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AUDIT PLAN EXERCISE
 Individually, begin to complete the Audit
Plan document for your business
Workplace Safety and Insurance Board | Commission de la sécurité professionnelle et de l’assurance contre les accidents du travail
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DOCUMENT REVIEW
CONDUCT AUDIT
 First step in conducting the audit
 Establishes initial conformity to audit criteria
 Determines other types of evidence to
sample
Mandatory audit
requirement
Workplace Safety and Insurance Board | Commission de la sécurité professionnelle et de l’assurance contre les accidents du travail
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DOCUMENT REVIEW
Documents vs. Records
CONDUCT AUDIT
 Document:
 May be a policy, procedure, work instruction,
form or other document that gives instruction
 It is current, active and changeable
 Records:
 Dated, historical and unchangeable
 An obsolete document may become
a record
Workplace Safety and Insurance Board | Commission de la sécurité professionnelle et de l’assurance contre les accidents du travail
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DOCUMENTS vs. RECORDS
 Documents
Lock out procedure
Orientation procedure
Inspection procedure
PPE procedure
Violence and
Harassment
procedure
 Health & Safety policy





 Records
 Lock out training
records
 Inspection reports
 PPE inspection log
 Investigation reports
 Violence and
Harassment
Assessment
 Posted H&S policy
Workplace Safety and Insurance Board | Commission de la sécurité professionnelle et de l’assurance contre les accidents du travail
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AUDIT EVIDENCE
CONDUCT
AUDIT
 Proof to demonstrate requirements have or have
not been met
 Sources of information gathered are grouped by:




Documentation
Records
Observation
Interviews
“A proof is a proof. What kind of a
proof? It's a proof. A proof is a
proof, and when you have a good
proof, it's because it's proven." –
Jean Chretien
Workplace Safety and Insurance Board | Commission de la sécurité professionnelle et de l’assurance contre les accidents du travail
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AUDIT EVIDENCE
DOCUMENTATION
- Verify relevant, clear and complete procedures, work
instructions, guidelines meet audit criteria
RECORDS
- Demonstrate that requirements of procedures and
standards have been met
OBSERVATIONS
- Verify implementation of standards
- Record observations (i.e. workers following rules)
INTERVIEWS
- To verify health & safety program understanding
Workplace Safety and Insurance Board | Commission de la sécurité professionnelle et de l’assurance contre les accidents du travail
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AUDIT EVIDENCE
CONDUCT
AUDIT
 If all available sources of information are
consistent then the information may be
considered evidence of conformity.
 Inconsistent information = nonconformity.
 Evidence is measured against:
 selected audit criteria AND
 requirements stated in the employer’s
standard
Workplace Safety and Insurance Board | Commission de la sécurité professionnelle et de l’assurance contre les accidents du travail
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COLLECTION & VERIFICATION
CONDUCT
AUDIT
 Review Documents and Records
 Note details of documents and records reviewed
 Observations:
 Note relevant actions that demonstrate conformity or
nonconformity
 Interviews during facility tour and/or the audit
 Appropriate to the situation and the person
 Interview people from appropriate levels and functions
 Use cross-section of the workplace
 Note evidence of conformity and nonconformity
 Summarize the results of the interview with the person
Workplace Safety and Insurance Board | Commission de la sécurité professionnelle et de l’assurance contre les accidents du travail
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AUDIT EVIDENCE
 What to observe
 Pre-use inspections
 Housekeeping
 Workers wearing PPE
 Workplace hazards
 Signage / safety postings
 Who do you interview?





Supervisors
Workers
Contractors
Engineers
JHSC members
Workplace Safety and Insurance Board | Commission de la sécurité professionnelle et de l’assurance contre les accidents du travail
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AUDIT EVIDENCE
 How much information is enough?
CONDUCT
AUDIT
 Sufficient to demonstrate a consistent pattern of
conformance
 One piece might be enough, for example:
 Maybe only one incident occurred so there will only be one
investigation report
 Observed one failure to use confined space procedure;
 10 to 50 pieces may be needed:
 Monthly workplace inspections
 Pre-shift forklift inspections
Workplace Safety and Insurance Board | Commission de la sécurité professionnelle et de l’assurance contre les accidents du travail
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AUDIT FINDINGS
CONDUCT
AUDIT
 Evaluate all audit evidence against audit criteria
 Audit findings indicate if there is a conformity or
non-conformity
 NOTE: any corrective actions to a nonconformity does not change audit findings
Workplace Safety and Insurance Board | Commission de la sécurité professionnelle et de l’assurance contre les accidents du travail
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AUDIT FINDINGS
 Conformity:
CONDUCT
AUDIT
 Fulfillment of the audit criteria that includes:
 Audit standard, policies, procedures, related
company rules AND
 Sufficient corroborating evidence from the
other three sources as applicable;
– Review and listing of required records
– Observations AND interviews
 Non-conformity:
 Non-fulfillment of, or deviation from, the
requirements
 Categorized as major or minor
Workplace Safety and Insurance Board | Commission de la sécurité professionnelle et de l’assurance contre les accidents du travail
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NON-CONFORMITIES
 Major:
CONDUCT
AUDIT
 The issue will continue to occur because of how
the HSMS and health and safety program are
structured
 There is unacceptable risk to a worker’s health or
safety
 There are serious legal implications, or
 There is an accumulation of related minor nonconformities
Workplace Safety and Insurance Board | Commission de la sécurité professionnelle et de l’assurance contre les accidents du travail
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NON-CONFORMITIES
 Minor:
 HSMS and H&S program structures are valid, but
there’s a minor deviation (e.g. human error)
 There is no unacceptable risk to the worker
 There are no significant legal implications, and
 There is not an accumulation of related minor nonconformities
 SGAP requires your Continuous Improvement Plan
(CIP) give priority to high-risk hazards and legal
requirements
Workplace Safety and Insurance Board | Commission de la sécurité professionnelle et de l’assurance contre les accidents du travail
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I used the wrong form for
the pre-start inspection.
What are you in for?
I didn’t complete the
health & safety survey.
Workplace Safety and Insurance Board | Commission de la sécurité professionnelle et de l’assurance contre les accidents du travail
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AUDIT REVIEW EXERCISE 2
CONDUCT
AUDIT
 In groups conduct a review of the audit criteria
against the evidence to determine conformity or
non-conformity:
 Identify the following:
 Audit lead
 Scribe
 Presenter
Workplace Safety and Insurance Board | Commission de la sécurité professionnelle et de l’assurance contre les accidents du travail
AUDIT REPORT
AUDIT
REPORT
 The audit report is a summary of auditor’s findings
 Completed audit is the most common report
submitted for management review
 Auditor can also create a separate audit report
with findings
 Report must reference evidence that supports the
findings of conformity and/or nonconformity for
each criteria
 Indicate any situations encountered that may
decrease the reliability of the audit conclusion
Workplace Safety and Insurance Board | Commission de la sécurité professionnelle et de l’assurance contre les accidents du travail
AUDIT REPORT
AUDIT
REPORT
 Diverging opinions about findings or conclusions
should be discussed, resolved if possible, and
recorded if not resolved
 The report must include the date(s) of the audit,
report date, auditor(s) name and signature
 Auditor(s) prepare to present or discuss the audit
with the Owner/Senior Management for their
review and signature
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END OF AUDITOR TRAINING
 Auditor training is now complete
 Time allowing….
 Management Review
 Continual Improvement Plan
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MANAGEMENT REVIEW
MANAGEMENT
REVIEW
 Owner / senior management review report
 Ensure the owner / senior management agrees
with and understands the audit conclusions
 A record of the Management Review is required
 usually a signature
 Establish timeframe for employer’s action plan
Workplace Safety and Insurance Board | Commission de la sécurité professionnelle et de l’assurance contre les accidents du travail
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CONTINUAL IMPROVEMENT PLAN
 Develop an action plan for all non-conformities
that includes:
 How non-conformities will be corrected,
 Responsibilities assigned and
 Timelines
ACTION PLAN
 Plan is developed or reviewed, approved,
resourced and initiated by the owner/senior
management .
 Record is required.
 The auditor(s) may conduct follow-ups to
ensure the element is progressing to conformity
Workplace Safety and Insurance Board | Commission de la sécurité professionnelle et de l’assurance contre les accidents du travail
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CONTINUAL IMPROVEMENT PLAN
 When a criteria requirement is met, but may
deteriorate into a nonconformity, the audit
report may indicate an opportunity to improve.
 The process of enhancing the HSMS to achieve
continual improvement in overall health and
safety performance.
ACTION PLAN
Workplace Safety and Insurance Board | Commission de la sécurité professionnelle et de l’assurance contre les accidents du travail
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CIP EXERCISE 3
 Choose 2 non-conformities and
 Develop a Continual Improvement
Plan (CIP) of how you will bring
items to conformity
MANAGEMENT
REVIEW &
ACTION PLAN
Workplace Safety and Insurance Board | Commission de la sécurité professionnelle et de l’assurance contre les accidents du travail
5. Continual Improvement Plan
(page 5)
5. Develop and implement a documented 2017 HSMS Audit
Continual Improvement Plan (CIP) including:
5.1 Detailed and specific action points for:
a. All audit findings of non-conformity, and
b. All RTW/WR non-conformities, and
c. All 2016 Audit/CIP Review (requirement 3) deficiencies
5.2 Priority will be given to non-conformities related to
Resources
& Tools
Samples of
Continual
Improvement
Plans
high- risk hazards, and legal requirements
5.3 Detailed action points for each non-conformity are
planned to resolution with responsibilities assigned and
timelines established
5.4 Senior management must review and approve the
documented CIP. Review must be documented.
Workplace Safety and Insurance Board | Commission de la sécurité professionnelle et de l’assurance contre les accidents du travail
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5. Continual Improvement Plan
(page 5)
5.5 Senior Management must review the progress of the
CIP on a quarterly basis until the CIP is completed
and all non-conformities are corrected. Quarterly
review must be documented.
5.6 The approved CIP must be started no later than
December 31, 2017, and all non-conformities and
deficiencies must have corrective action points that
are initiated within 6 months of the audit being
completed.
Resources
& Tools
Samples of
Continual
Improvement
Plans
NOTE: The development of the CIP often includes a firm undertaking a root cause analysis, and
other planning activities, to determine the appropriate corrective actions and resources for
each non-conformity. While these activities are important, they are not considered starting of
the CIP. See example below. Firms have the option to develop an individual CIP for an
individual non-conformity to expedite the implementation of corrective actions. Firms are
expected to prioritize their non-conformities and start their CIP with corrective action for nonconformities related to high-risk hazards and legal requirements.
Workplace Safety and Insurance Board | Commission de la sécurité professionnelle et de l’assurance contre les accidents du travail
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CIP ACTION PLAN EXAMPLE
NONCONFORMITY
ROOT CAUSE
ANALYSIS
ACTION PLAN
START PLAN
Aug. 1, 2017
Audit date
Sep. 15, 2017
Dec. 1, 2017
Dec. 15, 2017
Audit sec. 4.2 f
Worker observed
setting-up
production line A1
without locking-out
equipment.
The Operations
Department meet to
discuss the nonconformity.
The primary reason for
failure to lock-out is
determined to be faulty
equipment design.
Corrective measures will
require significant capital
expense – estimated at
$50,000.
Activity
Dates
1. Maintenance Supervisor to
develop and train staff on
interim lock-out procedure until
equipment is redesigned.
2. Operations Manager to
source and secure three
contract bids to re-engineer
faulty equipment.
3. Ops Manager and VP
Operations review and select
successful contract bid.
4. VP Operations secures
financing through budget
process.
5. Contractor completes work.
6. H&S Manager evaluates for
effectiveness.
Dec. 15, 2016
Mar. 1, 2017
Maintenance
Supervisor
documents interim
lock-out procedure
and training of all
appropriate staff.
Mar. 15, 2017
Apr. 30, 2017
Jul 31, 2017
Aug. 31, 2017
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AUDIT PROCESS
INITIATING
Document
Review
CONTINUAL
IMPROVEMENT
PLAN
CONDUCTING
THE AUDIT
Evidence
Findings
MANAGEMENT
REVIEW
AUDIT
REPORT
Workplace Safety and Insurance Board | Commission de la sécurité professionnelle et de l’assurance contre les accidents du travail
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Discussion and Questions
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